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Clinical Images

A Pain in the Butt

Authors: Christine R. McLaughlin, MD, Nicholas Apostolopoulos BA, Omoye Imoisili, MD, MPH, Lee David Katz, MD and Abhay J. Dhond, MD, MPH

A 41 year-old woman with no significant past medical history was admitted to the hospital for fevers and bilateral buttock pain, associated with lateral swelling, induration, and erythema.  Two years prior, she had received cosmetic buttock injections in Thailand with a filler known as Aqualift, and reported no procedural complications. Of note, she presented to an outside hospital one month prior to admission with similar symptoms and was empirically treated with vancomycin and piperacillin-tazobactam for a presumed cellulitis. However, she continued to have intermittent fevers, and thus, she was subsequently escalated to ertapenem. She was discharged home on long-term treatment with ertapenem.   

The patient was readmitted one month later to our hospital with persistent symptoms.  On exam, she had warmth, erythema, and edema with tenderness to palpation on the lateral buttocks bilaterally. A 10 mm non-tender pustule was noted midline above the gluteal cleft. Labs were notable for a white blood cell count of 9.5 x109/L and a C-reactive protein of 28.5 mg/L.  Blood cultures were negative. Magnetic resonance imaging (MRI) of bilateral hips showed extensive multilobulated, loculated fluid signals within the subcutaneous tissue replacing the gluteal muscles of the buttock region. With the addition of intravenous gadolinium, there was rim enhancement, suggestive of inflammation of the pseudocapsule of the buttock implants, as well as several other areas concerning for abscess formation (Figure 1). Empiric antibiotic coverage was resumed.  

Over the course of her hospitalization, she had increased tenderness over the site of the pustule above her gluteal cleft.  MRI did not indicate any evidence of subcutaneous tract below the pustule. Interestingly, within 12 hours of worsening tenderness, the pustule spontaneously ruptured, with release of opaque brown fluid. She subsequently underwent incision and drainage of the bilateral buttocks, extracting a total of 1700 mL of fat, filler, and blood.  Following the procedure, the patient reported immediate pain relief and was finally able to maintain a seated position. Deep wound culture from abscess drainage was positive for Parabacteroides distasonis, and the patient was discharged with a course of amoxicillin-clavulanic acid.   

Aqualift is a manufactured product more commonly seen in breast augmentation primarily used in Eastern Europe and Asia.  It contains a suspension of 2.5-5% polyacrylamide gel in sterile water1.  Although known for its ability to resist enzymatic degradation and phagocytosis given its high level of biocompatibility, the product has also been found to harbor bacteria1.  Adverse effects of Aqualift implantation include swelling, pain, and gel extrusion.  The product can also give rise to late infections, biofilms, and abscesses1. Infections typically develop 8-12 months following the implantation.

MCQ: Which of the following diagnoses would be least likely considering the patient’s history?

A. Chronic inflammatory reaction

B. Abscess formation

C. Type 1 mediated acute hypersensitivity reaction

D. Delayed type IV hypersensitivity reaction 

Click here for answer

About the authors:

Christine R. McLaughlin, MD, Resident-intern, Department of Anesthesiology, Yale New Haven Hospital, New Haven, Connecticut

Omoye Imoisili, MD, MPH, Resident, Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut

Nicholas Apostolopoulos, BA, Medical Student, Yale University School of Medicine

Lee David Katz, MD, Professor of Radiology and Biomedical Imaging and of Orthopaedics and Rehabilitation, Co-director of Musculoskeletal Imaging, Department of Radiology, Yale School of Medicine, New Haven, Connecticut

Abhay J. Dhond, MD, MPH, Assistant Clinical Professor of Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut